The Global Nutrition Report calls on governments, businesses and civil society to step up efforts to address malnutrition in all its forms and tackle injustices in food and health systems.

Everyone deserves access to healthy, affordable food and quality nutrition care. This access is hindered by deeper inequities that arise from unjust systems and processes that structure everyday living conditions.

This year’s Global Nutrition Report uses the concept of nutrition equity to elucidate these inequities and show how they determine opportunities and barriers to attaining healthy diets and lives, leading to unequal nutrition outcomes.

We examine the global burden of malnutrition with an equity lens to develop a fuller understanding of nutrition inequalities. In doing this, we pinpoint and prioritise key actions to amplify our efforts and propel progress towards ending malnutrition in all its forms.

The Global Nutrition Report calls for a pro-equity agenda that mainstreams nutrition into food systems and health systems, supported by strong financing and accountability. With only five years left to meet the 2025 global nutrition targets, time is running out. We must focus action where the need is greatest for maximum impact.

Today, one in every nine people in the world is hungry, and one in every three is overweight or obese. More and more countries experience the double burden of malnutrition, where undernutrition coexists with overweight, obesity and other diet-related non-communicable diseases (NCDs).

The trend is clear: progress is too slow to meet the global targets. Not one country is on course to meet all ten of the 2025 global nutrition targets and just 8 of 194 countries are on track to meet four targets.

Almost a quarter of all children under 5 years of age are stunted. At the same time, overweight and obesity are increasing rapidly in nearly every country in the world, with no signs of slowing.

Progress on malnutrition is not just too slow, it is also deeply unfair. New analysis shows that global and national patterns mask significant inequalities within countries and populations, with the most vulnerable groups being most affected. Nutrition outcomes also vary substantially across countries.

Underweight is a persisting issue for the poorest countries and can be ten times higher than in wealthier countries. Overweight and obesity prevail in wealthier countries at rates of up to five times higher than in poorer countries.

Within every country in the world, we see striking inequalities according to location, age, sex, education and wealth – while conflict and other forms of fragility compound the problem.

This report finds a strong urban–rural divide, and even larger differences across communities. In children under 5 years of age, wasting can be up to nine times higher in certain communities within countries, four times higher for stunting and three times higher for overweight and obesity.

There is a clear link between infant and young child feeding practices and household characteristics. Rates of solid food introduction and minimum diet diversity are substantially lower for children in the poorest households, in rural areas or with a less educated mother. Although more high-quality nutrition data is needed, we have enough to act.

Poor diets and resulting malnutrition are among the greatest current societal challenges, causing vast health, economic and environmental burdens. To fix the global nutrition crisis equitably, we must shift our approach dramatically in two ways: focusing on food and health.

First, we must address inequities in food systems, from production to consumption. Current food systems do not enable people to make healthy food choices. The vast majority of people today simply cannot access or afford a healthy diet. The reasons for this are complex.

Existing agriculture systems are largely focused on an overabundance of staple grains like rice, wheat and maize, rather than producing a broader range of more diverse and healthier foods, like fruits, nuts and vegetables.

Meanwhile, highly processed foods are available, cheap and intensively marketed; their sales are still high in high-income countries and growing fast in upper-middle- and lower-middle-income countries.

The climate emergency makes it critical to rethink food systems. And this presents an opportunity to shift to approaches ensuring that healthy and sustainably produced food is the most accessible, affordable and desirable choice for all.

These approaches must amplify the voices of marginalised groups and address the true cost of food to the environment, as well as to human health. Likewise, they must work both within specific contexts and across sectors to address all elements of the food system.

Second, we must address nutrition inequities in health systems. Malnutrition in all its forms has become the leading cause of ill health and death, and the rapid rise of diet-related NCDs is putting an intolerable strain on health systems. Yet, most people cannot access or afford quality nutrition care for prevention or treatment.

Worldwide, only about one-quarter of the 16.6 million children under 5 years of age with severe acute malnutrition received treatment in 2017, highlighting the urgent need to address this unacceptable burden.

Nutrition actions represent only a tiny portion of national health budgets, although they can be highly cost-effective and can reduce healthcare spending in the long term.

These are largely focused on undernutrition and are rarely delivered by skilled nutrition professionals. At the same time, health records and checks are not optimised to screen, monitor and treat malnutrition, such as through assessments of diet quality and food security.

Global commitment to universal health coverage is an opportunity to integrate nutrition care fully into health systems. Essential nutrition services – preventive and curative – should be universally available to all, with a focus on those who need it most.

Strong governance and coordination across sectors is key to building functional and resilient health systems. Mainstreaming and scaling up nutrition care within health systems would save lives and reduce staggering healthcare spending.

Only by tackling injustices in food and health systems will we achieve the transformations needed to end malnutrition in all its forms.

The intensified drive needed to meet global targets and end malnutrition is the collective responsibility of all sectors and countries. Domestic funding by country governments is crucial to ensure sustained improvements. At the same time, the international donor community has a duty to step up where governments lack the resources to respond effectively.

So far, investments have focused on addressing undernutrition. We have seen some success here, as rates of stunting are gradually decreasing over time. In contrast, overweight and obesity are rapidly increasing. The funding gap to address overweight, obesity and other diet-related NCDs is growing too. Countries have to be equipped to fight both sides of malnutrition at the same time.

We need to examine investments in nutrition through an equity lens. Investments must respond to need, and volumes of financing should be proportionate to the burden. We should proactively develop new financing mechanisms that can complement existing sources.

Nutrition inequalities exist across countries as well as within communities. Therefore, decisions on resource allocation by need should be informed by granular data at the subnational level, through evidence-based and cost-effective solutions. Coordination is essential to prioritise equitable nutrition investments.

Directing resources and programmes to communities and people most affected would enable faster, more equitable progress towards ending malnutrition.

Food is an important global issue – crucial to health, equity, sustainability, economies and livelihoods. Increased global recognition that governments, businesses and civil society are accountable for healthier and more equitable food and health systems provides an opportunity for us to invest in nutrition to preserve our future.

We urge leaders to prioritise action to ensure that all people, particularly those most affected by malnutrition, have unhindered access to healthy and affordable food, and to quality nutrition care. Governments must work with stakeholders across sectors to overcome the inequities holding back progress to end malnutrition.

To drive the transformative change needed to achieve nutrition equity, and end malnutrition in all its forms, we must focus on three key areas: food systems, health systems and financing.

Malnutrition in all its forms has become the leading cause of poor health and death, and the rapid rise of diet-related chronic diseases is putting an immense strain on health systems. But despite this assessment, nutrition actions only represent a minuscule portion of national health budgets although they can be highly cost-effective and cost-saving solutions.

To ensure that healthy and sustainably produced food is the most accessible, affordable and desirable choice for all, sectors must work together to mainstream nutrition into all elements of the food system including:

Implementing strong regulatory and policy frameworks to support healthier diets for all at country and community level and across sectors, from production to consumption. Optimise agricultural subsidies and increase public investment for producing a broader range of more diverse and healthier foods. Provide support for public transport schemes and shorter supply chains for fresh-food delivery products, particularly to the most nutritionally disadvantaged or harder-to-reach groups.

Implement, monitor and evaluate evidence-based food policies to support healthy, sustainable and equitable diets. Hold the food industry accountable for producing and marketing healthier and more sustainable food products through strengthened mechanisms.

Increase domestic financing to respond to the needs of communities most affected by malnutrition – including undernutrition, as well as overweight, obesity and other diet-related NCDs.

Increase international nutrition financing and coordination, targeting populations most in need – especially in fragile and conflict-affected countries and in those with limited possibility for domestic resource mobilisation.

Establish an international system of governance and accountability to address power imbalances in the food and health system and hold to account those responsible for creating inequities in food and health systems.

To save lives and cut healthcare costs, sectors must work in collaboration to mainstream nutrition as a basic health service.

At the beginning of April, the 2020 edition of the Global Report on Food Crises was issued, presenting a stark warning for the future. In 2019 – prior to the COVID-19 pandemic – 135 million people experienced “crisis” and worse levels of acute food insecurity.

A further 183 million were on the edge in “stressed” food security conditions. In other words, just one shock away from severe acute food insecurity. COVID-related restrictions risk pushing many more into crisis. As the pandemic progresses in food crisis contexts, food availability as well as food access could emerge as a serious concern – in both rural and urban areas.

As the situation evolves, there is a real concern about the growing risk of famine in some countries, potentially even several famines occurring simultaneously. Before the COVID-19 pandemic hit, globally tens of millions of people were in “emergency” levels of acute food insecurity, potentially on the brink of famine. The direct and indirect effects of the pandemic could have catastrophic effects on many of them.

In April 2020, the Famine Early Warning Systems Network (FEWS NET) Global Food Security Alert warned about the risk that populations in northeastern Nigeria, South Sudan and Yemen could face famine as consequence of the pandemic. In Somalia, the latest data from the Food Security and Nutrition Analysis Unit indicates around 3.5 million people are projected to be in IPC Phase 3 and above through September – a three fold increase compared with early 2020.

Anticipatory action to safeguard livelihoods and increase access to food is urgently needed to prevent new or worsening food crises.

Preventing food crises cannot wait until the health crisis is resolved. Impacts on food access are already being seen, even in the world’s wealthiest countries. For those living in contexts already experiencing food crises as a result of conflict, climate or economic instability, there is no time to waste.

Up to 80 percent of people living in these contexts rely on some form of agricultural production for their livelihoods. Even in countries, such as Yemen, that rely heavily on imports, locally produced food plays an important role in meeting people’s needs and especially in ensuring dietary diversity.

While the challenges facing vulnerable rural populations differ significantly according to the context and the evolutions of the pandemic, there are a number of common risks, including planting affected by reduced access to inputs due to limited market access and reduced incomes; harvesting disrupted by lack of seasonal labour; transport to markets reduced due to movement restrictions; and markets themselves constrained by lockdowns, physical distancing and lower purchasing power.

Responding to these challenges requires urgent action. Critical agricultural seasons, livestock movements for pasture and water, harvesting activities cannot be put on hold as we tackle the virus.

Without support, many vulnerable people will be forced to rely on humanitarian assistance just to survive – a humanitarian system already stretched to its limits before COVID 19.

Anticipatory action now to avert deteriorating or emerging food crises is not just more cost effective than waiting to rebuild livelihoods and communities later, it is more humane and respectful of the dignity of the millions of people relying on some form of agriculture for their livelihoods.

The Global COVID-19 Humanitarian Response Plan has been revised to reflect the increasingly urgent need to address non-health impacts of COVID-19. Of these needs, the food security sector represents a critical component. As part of this, the Food and Agriculture Organization of the United Nations (FAO) is seeking USD 350 million to ensure the provision of critical assistance where there are already high levels of need, while meeting new needs emerging from the effects of COVID-19.

FAO will focus on stabilizing incomes and access to food as well as preserving ongoing livelihood and food production assistance for the most acutely food insecure populations; ensuring continuity of the critical food supply chain for the most vulnerable populations; and ensuring people along the food supply chain are not at risk of COVID 19 transmission through awareness raising, social messaging and community mobilization.

The Director-General of the UN Food and Agriculture Organization (FAO), QU Dongyu, has urged leaders from the G20 countries to take measures for global food systems to continue to work well, particularly in relation to access to food for the world''s poor and most vulnerable during the COVID-19 pandemic.

He made the appeal in an address to the G20 Leaders Summit on COVID-19. The summit was called to forge a coordinated global response to the COVID-19 pandemic and its human and economic implications.

"The COVID-19 pandemic is affecting food systems and all dimensions of food security across the world," Qu said. "No country is immune."

"We have to ensure that food value chains are not disrupted and continue to function well and promote the production and availability of diversified, safe and nutritious food for all," he said.

The Director-General said lockdowns and restrictions on movement could disrupt food production, processing, distribution and sales, both nationally and globally, with the potential to have an "immediate and severe" impact on those restricted by mobility.

"The poor and the vulnerable will be the hardest hit, and governments should strengthen social safety mechanisms to maintain their access to food," he said.

He said global food markets are well supplied but there is growing concern and that measures should be taken to ensure that both national food markets and the world market continue to be a transparent, stable and reliable source of food supply.

Referring to the 2007-08 global food price crisis, the Director-General said uncertainty at that time triggered a wave of export restrictions by some countries, while others started importing food aggressively. Qu said this contributed to excessive price volatility, which was damaging for low-income food-deficit countries.

As economic activities slow down due to the COVID-19 pandemic, access to food will be negatively affected by income reductions and loss of employment.

"We need to make sure that agricultural trade continues to play its important role in contributing to global food security and better nutrition," Qu said.

Protectionist measures by national governments during the coronavirus crisis could provoke food shortages around the world, the UN’s food body has warned.

Harvests have been good and the outlook for staple crops is promising, but a shortage of field workers brought on by the virus crisis and a move towards protectionism – tariffs and export bans – mean problems could quickly appear in the coming weeks, Maximo Torero, chief economist of the UN Food and Agriculture Organisation, told the Guardian.

“The worst that can happen is that governments restrict the flow of food,” he said. “All measures against free trade will be counterproductive. Now is not the time for restrictions or putting in place trade barriers. Now is the time to protect the flow of food around the world.”

Governments must resist calls from some quarters to protect their own food supply by restricting exports, he said, as some have begun to do.

Kazakhstan, for instance, according to a report from Bloomberg, has banned exports of wheat flour, of which it is one of the world’s biggest sources, as well as restrictions on buckwheat and vegetables including onions, carrots and potatoes. Vietnam, the world’s third biggest rice exporter, has temporarily suspended rice export contracts.

Russia, the world’s biggest wheat exporter, may also threaten to restrict exports, as it has done before, and the position of the US is in doubt given Donald Trump’s eagerness for a trade war in other commodities.

“Trade barriers will create extreme volatility,” warned Torero. “They will make the situation worse. That’s what we observe in food crises.”

While the supply of food is functioning well in most countries at present, problems could start to be seen within weeks and intensify over the following two months as key fruit and vegetables come into season. These types of produce often have short ripening times and are highly perishable, and need skilled pickers to work quickly at the right time.

“We need to be careful not to break the food value chain and the logistics or we will be looking at problems with fresh vegetables and fruits soon,” said Torero. “Fruit and vegetables are also very labour intensive, if the labour force is threatened because people can’t move then you have a problem.”

As governments impose lockdowns in countries across the world, recruiting seasonal workers will become impossible unless measures are taken to ensure vital workers can still move around, while preventing the virus from spreading.

“Coronavirus is affecting the labour force and the logistical problems are becoming very important,” said Torero. “We need to have policies in place so the labour force can keep doing their job. Protect people too, but we need the labour force. Major countries have yet to implement these sorts of policies to ensure that food can keep moving.”

Countries with high level of imports, are also likely to see food price rises unless the government takes action or retailers absorb some of the costs, he said.

The most important role governments can play is to keep the food supply chain operating, intervene to ensure there are enough workers, and keep the global food markets from panicking, according to Torero.

“If traders start to become nervous, conditions will get difficult,” he said. “It just needs one big trader to make a decision [to disrupt the supply of staple crops] and that will affect everywhere. Governments must properly regulate, that is their biggest function in this situation.

It’s very important to keep alive the food value chain: intervene to protect the value chain [including the supply of workers] but not to distort the market.”

Animal welfare is also an issue as border delays caused by the Covid-19 lockdown measures are meaning that livestock journeys are lengthened.

In this interview, Dominique Burgeon, Director of the FAO Emergency and Resilience Division, explains the particular challenges COVID-19 poses in vulnerable communities already coping with high levels of hunger due to pre-existing crises -- and how the Organization is gearing up to help.

Which communities are most at risk from the food security and livelihood impacts of the pandemic?

Even before COVID-19 hit, 113 million people on the planet were already struggling with severe acute food insecurity due to pre-existing shocks or crises. This means they were already on the extreme end of the hunger spectrum-weak, and less well-equipped to fend off the virus.

The vast majority live in rural areas, and depend on agricultural production, seasonal jobs in agriculture, fishing, or pastoralism. If they become ill or constrained by restrictions on movement or activity, they will be prevented from working their land, caring for their animals, going fishing, or accessing markets to sell produce, buy food, or get seeds and supplies.

These people have very little to fall back on, materially speaking. They could find themselves forced to abandon their livelihoods. By that I mean they''ve might have to sell off their animals or their fishing boat for cash. Or eat all of their seeds instead of saving some to replant.

Once a rural farming family does that, getting to be self-reliant again becomes extremely difficult. Some might even have no other choice than to leave their farms in search of assistance.

Has something like this happened before?

There are some similarities with the 2014 West Africa Ebola outbreak. That disrupted agricultural market supply chains. Many farmers couldn''t grow or sell crops. This, plus agricultural labour shortages, impacted food production. In Liberia, 47 percent of farmers were unable to cultivate. Restrictions and market closures disrupted flows of food and necessities. Shortages of goods led to an increase in prices of key commodities.

The nutritional impact was predominantly attributable to reduced food access -- driven by a reduction in economic activity that reduced families purchasing power. People went hungry.

So the lessons from the 2014 EVD outbreak are clear: while health needs are an urgent and primary concern, we cannot neglect livelihoods or food security aspects. Also, when people''s livelihoods are disrupted, that can spark tensions and social unrest.

How so?

Well, if food supply chains become disrupted and livelihoods untenable, vulnerable populations may be more likely to leave behind their livelihoods and move in search of assistance - as would any of us - with the unintended consequence of potentially further spreading the virus and possibly encountering heightened social tensions.

For pastoralists, the disruption of traditional transhumance patterns may lead to tensions and even violent conflicts between resident and pastoralist communities, resulting in local displacement and increased levels of poverty and food insecurity.

Where do the people most at risk live?

To give one example, in Ethiopia, Kenya, Somalia nearly 12 million people already found themselves in dire circumstances as a result of extended severe droughts and back-to-back failed harvests before hordes of desert locusts descended on their crops and pastures in late December/early January.

In Africa, we are also worried about the Sahel, the Central African Republic, the Democratic Republic of the Congo, and South Sudan to name a few food crises. But no continent is immune. From Afghanistan to Haiti to Syria to Myanmar, COVID-19 risks further exacerbating the impact of conflicts and natural disasters.

We will be working everywhere we are needed, but FAO''s response strategy will prioritize countries already facing food crises, as per the Global Report on Food Crises. Our work will adapt to the evolution of the pandemic, which may see rising needs in countries not currently in crisis but that are extremely vulnerable to a new shock.

Are COVID-19 impacts on food security and livelihoods already being felt in these places?

In terms of understanding the extent of the health dimension, this is the mandate of WHO and other colleagues, and they are working mightily to get a better understanding in these contexts.

For FAO, our focus is the concern that as the number of infections in vulnerable countries grows -- among populations who are already malnourished, weak and vulnerable to disease -- a "crisis within a crisis" could emerge, in which the health crisis will be compounded by a hunger crisis. And that, in a vicious feedback loop, will leave more people weaker and vulnerable to the virus.

New cases are being reported every day in all of the countries we are concerned about. Getting a better understanding of the impact of the disease on food security is a top priority, so we can rapidly deploy the right kinds of responses and strategically target them to meet needs.

Tell us more about how FAO plans to respond.

We are moving to sustain and then scale up our critical livelihood saving programs in countries coping with protracted crises or pre-existing high levels of food insecurity. The UN system on 25 March launched a consolidated humanitarian appeal under which FAO asked donors for support to protect the food security of vulnerable rural populations.

In addition to improve data gathering and analysis to inform decision-making, we will be stabilizing incomes and access to food as well as preserving livelihoods.

This means providing smallholder farmers and herders with seeds, tools, livestock feed and other inputs, along with animal health support, so they can continue to produce food for their families and communities and generate income.

We will also distribute seeds and home gardening kits, food storage systems, and poultry and other small stock to improve household nutrition and diversify incomes. Similar activities will be undertaken in camps for refugees and the displaced.

Social protection schemes will be a critical tool and we are engaging with governments, local organizations and others to look at ways we can scale up existing systems, especially in hard-to-reach rural areas. One key way to stabilize families purchasing power will be through injections of cash, so they can meet critical household needs without selling off their assets.

We''ll also work to ensure the continuity of the food supply chain -- including between rural, peri-urban and urban areas -- by supporting through various activities the functioning of local food markets, value chains and systems.

And will help make sure that people along the food supply chain are not at risk of COVID-19 transmission, by raising awareness about food safety and health best practices. In this effort, we will be collaborating both, with national authorities and the World Health Organization - as we did in the Ebola crisis.

How will FAO manage to deliver, given travel and other restrictions?

Slow-downs or reductions in the delivery of humanitarian assistance could be catastrophic in crises. But the humanitarian community is readjusting. FAO country offices are consulting with local partners we''ve worked with for years and who are for the most embedded with the communities we serve, adapting flexible arrangements to combine logistics channels for aid delivery and minimize exposure of staff and beneficiaries.

We are also looking at advance procurement of inputs (such as seeds, tools) and pre-positioning, combining input packages to cover longer-term needs, and increasing storage and logistics capacities.

Many wealthy nations are themselves struggling with COVID-19. Will this affect funding for humanitarian action?

It is a legitimate worry, but we are seeing some signs it is not the case. Perhaps one silver lining of the pandemic is that the shared realization that we''re all in this together. Even as we are all focused --understandably-on the wellbeing of our own families, neighbors, and countries, we''ve also come to understand that this virus does not respect borders.

If we beat it back in the developed world but allow it to go unchecked in less-resourced countries whose medical systems struggle to cope and where people are already weak from hunger and less able to withstand the disease, it will come back to haunt us all.

Why should resources go to agricultural livelihoods and food systems, instead of hospitals?

While the human health dimension is no doubt hugely important, the concerns we''re flagging and the work we''re aiming to do will be critical to getting through to the other side without additional and unnecessary human tragedy. Keep in mind that we have over 110 million people in acute food insecurity, this means that these people are extremely vulnerable and that one more shock can push them closer to famine.

Also, if we let people''s livelihoods be lost as a result of this pandemic, once the human health crisis has eased, we will have major problems to deal with, afterwards. It is both more humane and strategically smarter to protect and sustain livelihoods now, rather than rebuild them after.